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1.  A pictorial overview of pubovisceral muscle avulsions on pelvic floor magnetic resonance imaging 
Insights into Imaging  2013;4(4):431-441.
Objectives
Despite extensive research aimed at clarifying (failing) pelvic organ support, the complete aetiology of pelvic organ prolapse (POP) is still not fully understood. During vaginal delivery, the pelvic floor can be irreversibly traumatised, resulting in pubovisceral muscle avulsions. The aetiology of these avulsions is discussed in this pictorial overview. Normal female pelvic floor anatomy is described and variations are exemplified using magnetic resonance (MR) images. The clinical relevance of detecting pubovisceral muscle avulsions is specified.
Methods
T2-weighted MR imaging has multiplanar capabilities with high diagnostic accuracy allowing for detailed visualisation of the pelvic floor. Together with the use of a three-dimensional (3D) post-processing program, the presence and severity of pubovisceral muscle avulsions can be quantified.
Results
Pelvic floor MR imaging is a non-invasive method that enables adequate identification of pubovisceral muscle avulsions which are known risk factors for the development of POP. They can be scored with good to excellent inter- and intra-observer reliability.
Conclusions
Radiologists and urogynaecology subspecialists should be familiar with MR imaging findings of pubovisceral muscle avulsions as this birth-related trauma is observed in over 36 % of vaginally parous women.
Teaching Points
• Pelvic organ prolapse (POP) is a growing problem for both patients and for our healthcare system
• Pubovisceral muscle avulsions are known risk factors for pelvic organ prolapse (POP)
• T2-weighted MR imaging visualises pubovisceral muscle avulsions adequately
• Pubovisceral muscle avulsions are scored with good to excellent inter- and intra-observer reliability
doi:10.1007/s13244-013-0261-9
PMCID: PMC3731469  PMID: 23756995
Injuries; Magnetic resonance imaging; Parturition; Pelvic floor; Pelvic organ prolapse
2.  Identification of Six Loci Associated With Pelvic Organ Prolapse Using Genome-Wide Association Analysis 
Obstetrics and gynecology  2011;118(6):1345-1353.
Objective
There is evidence that both environmental and genetic factors contribute to pelvic organ prolapse (POP). We conducted a genome-wide association study to investigate whether common genetic variants modify the risk of POP.
Methods
We recruited women who had been evaluated and treated for POP at the University of Utah from 1996–2008 and their affected female relatives. Cases were genotyped on the Illumina 550K platform. We genetically matched 2,976 Caucasian iControls available from Illumina as controls. Association tests were adjusted for related subjects using two different software programs: Efficient Mixed-Model Association eXpedited (EMMAX) and Genie. Confirmation of findings was performed in a cohort of Dutch women (n=76) with recurrent POP and family history of POP.
Results
The Utah study sample included 115 cases treated for POP, in most cases with surgery (n=78) or repeat surgery (n=35). Results from association analyses using EMMAX software identified five single nucleotide polymorphisms (SNPs) significantly associated with POP (p<1×10−7). Independent association analysis with Genie software identified three of the same SNPs and one additional SNP. The six SNPs were located at 4q21 (rs1455311), 8q24 (rs1036819), 9q22 (rs430794), 15q11 (rs8027714), 20p13 (rs1810636), and 21q22 (rs2236479). Nominally significant findings (p<0.05) or findings trending towards significance (p<0.1) were observed for five of the six SNPs in the Dutch cohort.
Conclusion
Six SNPs have been identified that are significantly associated with POP in high-risk familial cases and provide evidence for a genetic contribution to POP.
doi:10.1097/AOG.0b013e318236f4b5
PMCID: PMC3233378  PMID: 22105264
3.  Diagnosing pubovisceral avulsions: a systematic review of the clinical relevance of a prevalent anatomical defect 
International Urogynecology Journal  2012;23(12):1653-1664.
The aims of this systematic literature review were to assess whether the detection of pubovisceral avulsions using magnetic resonance (MR) imaging or perineal ultrasonography was clinically relevant in women with pelvic floor dysfunction and to evaluate the relation with anatomy, symptoms, and recurrence after surgery. We performed a systematic literature review using three bibliographical databases (PubMed, Embase, and CINAHL) as data sources. Clinical studies were included in which pubovisceral avulsions were studied in relation to pelvic organ prolapse (POP) stage, pelvic floor symptoms, and/or recurrence of POP after surgery. Ultimately, 21 studies met the inclusion criteria. POP stage and recurrence of POP after surgery were strongly associated with pubovisceral avulsions. Contradictory results were found regarding the relation between pubovisceral avulsions and urinary symptoms and symptoms of anorectal dysfunction. Pubovisceral avulsions, as diagnosed by MR imaging or perineal ultrasonography, are associated with higher stages of POP and recurrence of POP after surgery.
doi:10.1007/s00192-012-1805-0
PMCID: PMC3515771  PMID: 22581241
Levator ani; Levator defect; MR imaging; Perineal ultrasonography; Pubovisceral avulsion
4.  A systematic review of clinical studies on hereditary factors in pelvic organ prolapse 
International Urogynecology Journal  2012;23(10):1327-1336.
Introduction and hypothesis
There is growing evidence that pelvic organ prolapse (POP) is at least partly caused by underlying hereditary risk factors. The aim of our study was to provide a systematic literature review and meta-analysis of clinical studies on family history of POP as a risk factor for POP in individual women.
Methods
The databases PubMed and Embase were searched. Clinical studies reporting on family history of POP in relation to POP in individual women were included.
Results
Sixteen studies were included, of which eight enabled us to calculate a pooled odds ratio (OR). The pooled OR of POP in case of a positive family history of POP was 2.58 (95 % confidence interval 2.12–3.15).
Conclusions
Women with POP are substantially more likely to have family members with the same condition compared to women without POP. This strengthens the hypothesis that genetic predisposition plays an important role in the development of POP.
doi:10.1007/s00192-012-1704-4
PMCID: PMC3448053  PMID: 22422218
Family; Genetics; Inheritance; Pelvic organ prolapse; Review
5.  Laparoscopic sacrocolpopexy with bone anchor fixation: short-term anatomic and functional results 
Introduction and hypothesis
The aim of this study was to evaluate short-term anatomic and functional outcomes and safety of laparoscopic sacrocolpopexy with bone anchor fixation.
Methods
A prospective cohort study of women undergoing laparoscopic sacrocolpopexy between 2004 and 2009. Anatomic outcome was assessed using the pelvic organ prolapse quantification score (POP-Q). Functional outcomes were assessed using the Urogenital Distress Inventory, Defecatory Distress Inventory, and the Incontinence Impact Questionnaire preoperatively and at 6 months postoperatively. The Wilcoxon signed rank test was used to test differences between related samples.
Results
Forty-nine women underwent laparoscopic sacrocolpopexy. The objective success rate in the apical compartment was 98%, subjective success rate was 79%. One mesh exposure (2%) was found. One conversion was necessary due to injury to the ileum.
Conclusions
Laparoscopic sacrocolpopexy with bone anchor fixation is a safe and efficacious treatment for apical compartment prolapse. It provides excellent apical support and good functional outcome 6 months postoperatively.
doi:10.1007/s00192-011-1599-5
PMCID: PMC3305870  PMID: 22086264
Bone anchor fixation; Functional outcome; Laparoscopy; Pelvic organ prolapse; Sacrocolpopexy
6.  The value of preoperative urodynamics according to gynecologists and urologists with special interest in stress urinary incontinence 
Introduction and hypothesis
The aim of this study is to assess variations in practice in the use of preoperative urodynamics in women with stress urinary incontinence (SUI).
Methods
We performed an E-survey among all Dutch gynecologists and urologists who have SUI as focus in daily practice. The questions concerned the common policy and preferred policy. Descriptive statistics were used.
Results
Of the 260 targeted specialists, 163 (63%) responded. We found that 37% of the respondents performed standard preoperative urodynamics; in the preferred practice, this would reduce to only 18%. Eighty percent indicated they would operate a patient with a positive stress test without urodynamic SUI, whereas 21% would do this also in case the clinical stress test was negative. Only 9% of the respondents indicated they adapted the choice of the type of sling based on urethral pressure profilometry parameters.
Conclusions
Urodynamics are not routinely performed, and outcomes hardly influence the choice of treatment.
Electronic supplementary material
The online version of this article (doi:10.1007/s00192-011-1565-2) contains supplementary material, which is available to authorized users.
doi:10.1007/s00192-011-1565-2
PMCID: PMC3305873  PMID: 21927939
Urodynamics; Stress urinary incontinence; Surgery; Practice variation
7.  Pelvic organ prolapse and collagen-associated disorders 
Introduction and hypothesis
Pelvic organ prolapse (POP) and other disorders, such as varicose veins and joint hypermobility, have been associated with changes in collagen strength and metabolism. We hypothesized that these various disorders were more prevalent in both POP patients and their family members.
Methods
In this study, the prevalence of various collagen-associated disorders, including POP, was compared between POP patients (n = 110) and control patients (n = 100) and their first and second degree family members.
Results
POP patients reported a higher prevalence of varicose veins, joint hypermobility and rectal prolapse and were more likely to have family members with POP as compared to the control group (p < 0.01). In contrast, the family members of the POP group did not report a higher prevalence of collagen-associated disorders compared to the family members of the control group (p = 0.82).
Conclusions
POP and other collagen-associated disorders may have a common aetiology, originating at the molecular level of the collagens.
doi:10.1007/s00192-011-1532-y
PMCID: PMC3282004  PMID: 21811768
Pelvic organ prolapse; Collagen; Heredity; Varicose veins; Rectal prolapse; Joint hypermobility
8.  Surgical management of mesh-related complications after prior pelvic floor reconstructive surgery with mesh 
International Urogynecology Journal  2011;22(11):1395-1404.
Introduction and hypothesis
The objective of this study is to evaluate the complications and anatomical and functional outcomes of the surgical treatment of mesh-related complications.
Methods
A retrospective cohort study of patients who underwent complete or partial mesh excision to treat complications after prior mesh-augmented pelvic floor reconstructive surgery was conducted.
Results
Seventy-three patients underwent 30 complete and 51 partial mesh excisions. Intraoperative complications occurred in 4 cases, postoperative complications in 13. Symptom relief was achieved in 92% of patients. Recurrence of pelvic organ prolapse (POP) occurred in 29% of complete and 5% of partial excisions of mesh used in POP surgery. De novo stress urinary incontinence (SUI) occurred in 36% of patients who underwent excision of a suburethral sling.
Conclusions
Mesh excision relieves mesh-related complications effectively, although with a substantial risk of serious complications and recurrence of POP or SUI. More complex excisions should be performed in skilled centers.
doi:10.1007/s00192-011-1476-2
PMCID: PMC3187855  PMID: 21681595
Complications; Excision; Exposure; Mesh; Pelvic organ prolapse; Stress urinary incontinence
9.  Between hope and fear: patient’s expectations prior to pelvic organ prolapse surgery 
International Urogynecology Journal  2011;22(9):1159-1163.
Introduction and hypothesis
The aim of our study was to analyse the patient’s expectations (fears and goals (hopes)) in women who are scheduled for pelvic organ prolapse (POP) surgery.
Methods
All consecutive women awaiting surgery for POP in a tertiary urogynaecological centre were included. A short questionnaire with two open questions on goals and fears with regard to the operation was used.
Results
Ninety-six out of 111 distributed questionnaires (86%) were analysed. Goals and fears were categorized into five groups. De novo symptoms (63%), POP recurrence (34%) and surgical complications (29%) were the most important fears. Symptom release (96%), improved lifestyle (physical capabilities; 30%) and improved sexual life (18%) were important goals.
Conclusions
A wide variety of expectations both positive and negative can be found in women before POP surgery and should be an integral part of preoperative counselling. Achieving the individual goals as based on expectations, positive (goals) and negative (fears), should be part of the POP surgery evaluation.
doi:10.1007/s00192-011-1448-6
PMCID: PMC3162144  PMID: 21604059
Pelvic organ prolapse; POP surgery; Hopes; Fears; Expectations
10.  Surgical treatment of uterine prolapse in women with bladder exstrophy: report of two cases with modified Prolift™ procedure 
The incidence of pelvic organ prolapse is 18% in women with bladder exstrophy. A vaginal technique to correct the prolapse may be preferable in these women with multiple abdominal operations in their histories. We have performed a modified Prolift™ procedure for the repair of severe uterine prolapse in two young women. A review of the literature is presented.
doi:10.1007/s00192-011-1368-5
PMCID: PMC3112350  PMID: 21360218
Bladder exstrophy; Fertility; Surgical mesh; Uterine prolapse
11.  Rectal obstruction after a vaginal posterior compartment polypropylene mesh fixed to the sacrospinous ligaments 
International Urogynecology Journal  2011;22(8):1035-1037.
We present a case in which a polypropylene mesh was placed over the posterior vaginal wall and was fixed to the sacrospinous ligaments on both sides. Postoperative a rectal obstruction developed which was only resolved after splitting the entire mesh in the midline. It is hypothesised that the obstruction was due to the fixation of the mesh with irresolvable suture material to the sacrospinous ligaments acting as a hinge on which the bowel folded.
doi:10.1007/s00192-011-1376-5
PMCID: PMC3132279  PMID: 21360217
Mesh; Complication; Surgery; Rectocele; Obstruction
12.  Technique of anterior colporrhaphy: a Dutch evaluation 
Introduction and hypothesis
To evaluate the variation in techniques of anterior colporrhaphy among members of the Dutch Urogynecologic Society.
Methods
A questionnaire evaluating the technique of anterior colporrhaphy, preoperative and postoperative care, and use of the POP-Q score was sent out by e-mail.
Results
One hundred thirty-three completed questionnaires were received. The response rate was 65%. There are large variations in incisions, use of hydrodissection, method of plication, and excision of redundant vaginal epithelium. The urinary catheter was generally removed on day 2 after surgery and the vaginal pack on day 1. Less than half of the respondents used the POP-Q score routinely.
Conclusions
Dutch gynecologists use a variety of surgical techniques to operate on a cystocele. This suggests that there is no widely accepted opinion on the best surgical approach. The lack of differentiation between central and lateral defects is striking and in contrast with the, mostly, American literature.
doi:10.1007/s00192-010-1353-4
PMCID: PMC3072509  PMID: 21350970
Anterior colporrhaphy; Cystocele; Pelvic organ prolapse; POP-Q
13.  Treatment of uterine prolapse stage 2 or higher: a randomized multicenter trial comparing sacrospinous fixation with vaginal hysterectomy (SAVE U trial) 
BMC Women's Health  2011;11:4.
Background
Pelvic organ prolapse is a common health problem, affecting up to 40% of parous women over 50 years old, with significant negative influence on quality of life. Vaginal hysterectomy is currently the leading treatment method for patients with symptomatic uterine prolapse. Several studies have shown that sacrospinous fixation in case of uterine prolapse is a safe and effective alternative to vaginal hysterectomy. However, no large randomized trials with long-term follow-up have been performed to compare efficacy and quality of life between both techniques.
The SAVE U trial is designed to compare sacrospinous fixation with vaginal hysterectomy in the treatment of uterine prolapse stage 2 or higher in terms of prolapse recurrence, quality of life, complications, hospital stay, post-operative recovery and sexual functioning.
Methods/design
The SAVE U trial is a randomized controlled multi-center non-inferiority trial. The study compares sacrospinous fixation with vaginal hysterectomy in women with uterine prolapse stage 2 or higher. The primary outcome measure is recurrence of uterine prolapse defined as: uterine descent stage 2 or more assessed by pelvic organ prolapse quantification examination and prolapse complaints and/or redo surgery at 12 months follow-up. Secondary outcomes are subjective improvement in quality of life measured by generic (Short Form 36 and Euroqol 5D) and disease-specific (Urogenital Distress Inventory, Defecatory Distress Inventory and Incontinence Impact Questionnaire) quality of life instruments, complications following surgery, hospital stay, post-operative recovery and sexual functioning (Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire). Analysis will be performed according to the intention to treat principle. Based on comparable recurrence rates of 3% and considering an upper-limit of 7% to be non-inferior (beta 0.2 and one sided alpha 0.025), 104 patients are needed per group.
Discussion
The SAVE U trial is a randomized multicenter trial that will provide evidence whether the efficacy of sacrospinous fixation is similar to vaginal hysterectomy in women with uterine prolapse stage 2 or higher.
Trial registration
Netherlands Trial Register (NTR): NTR1866
doi:10.1186/1472-6874-11-4
PMCID: PMC3045971  PMID: 21324143
14.  The prevalence and risk factors of overactive bladder symptoms and its relation to pelvic organ prolapse symptoms in a general female population 
Introduction and hypothesis
To study the prevalence and risk factors of overactive bladder (OAB) symptoms and its relationship with symptoms of pelvic organ prolapse (POP).
Methods
This is a cross-sectional study including women aged between 45 and 85 years, registered in eight general practices. All women were asked to self complete the validated Dutch translated questionnaires. All symptoms were dichotomized as present or absent based on responses to each symptom and degree of bother.
Results
Forty-seven percent of the women filled out the questionnaire. Prevalence of urgency was 34% and the prevalence of any OAB symptoms 49%. Prevalence of OAB symptoms increased with advancing age. Symptoms of POP were an independent risk factor for symptomatic OAB. Other risk factors were continence and prolapse surgery in the past, age above 75, overweight, postmenopausal status and smoking.
Conclusions
The prevalence of any OAB symptoms was 49%. POP symptoms were an independent risk factor for symptomatic OAB.
doi:10.1007/s00192-010-1323-x
PMCID: PMC3072516  PMID: 21104400
Overactive bladder; Urgency; Urge incontinence; Frequency; Pelvic organ prolapse; Prevalence
15.  A fetal scalp electrode as a simple aid in the search for a lost needle fragment during sacrospinous ligament fixation 
A needle fragment was lost during a sacrospinous ligament fixation. This was recognized during the procedure, but could not be found at that moment. The patient complained of severe buttock pain postoperatively. The needle fragment was localized on CT scan of the pelvis. A fetal scalp electrode helped as a search device to localize the needle on X-ray during the secondary surgery. The patient was operated successfully and was free of pain after 6 weeks.
doi:10.1007/s00192-010-1247-5
PMCID: PMC3025122  PMID: 20798923
Buttock pain; Fetal scalp electrode; Needle; Sacrospinous ligament fixation
16.  Gynaecologists estimate and experience laparoscopic hysterectomy as more difficult compared with abdominal hysterectomy 
Gynecological Surgery  2010;7(4):359-363.
The level of difficulty of various types of hysterectomy differs and may influence the choice of either approach. When surgeons consider one specific approach to hysterectomy as more difficult, they may be reluctant to perform this type of hysterectomy. The main objective of this study was to investigate the potential different levels of difficulty for laparoscopic and abdominal hysterectomy. Furthermore, the accuracy of estimating the level of difficulty was examined. In a randomized controlled trial between laparoscopic hysterectomy (LH) and abdominal hysterectomy (AH), gynaecologists were asked to record the preoperatively estimated and postoperatively experienced level of difficulty on a Visual Analogue Scale (VAS). Differences between LH and AH were examined and the correlation between the estimated uterine weight on bimanual palpation and the actual uterine weight was calculated. A difference on the VAS of three points or more (ΔVAS ≥ 3) was considered clinically relevant. In 72 out of 76 cases, both VAS scores were recorded. LH was estimated and experienced as significantly more difficult as compared with AH. In 13 (18%) cases, ΔVAS was ≥3, equally distributed between LH (n = 6) and AH (n = 7). Eleven of these 13 cases had a positive ΔVAS ≥3, meaning that surgery was experienced as more difficult than it was estimated. Surgeon’s estimation of uterine size correlated well with the actual uterine weight. LH is considered as more difficult than AH, which might be a reason for its slow implementation. In a large proportion of cases, gynaecologists seem to be able to estimate the level of difficulty of hysterectomy accurately.
doi:10.1007/s10397-010-0592-1
PMCID: PMC2974921  PMID: 21124999
Randomized trial; Laparoscopic hysterectomy; Abdominal hysterectomy; Level of difficulty
17.  Predictive factors for overactive bladder symptoms after pelvic organ prolapse surgery 
International Urogynecology Journal  2010;21(9):1143-1149.
Introduction and hypothesis
This study focussed on the factors which predict the presence of symptoms of overactive bladder (OAB) after surgery for pelvic organ prolapse (POP).
Methods
Consecutive women who underwent POP surgery with or without the use of vaginal mesh materials in the years 2004–2007 were included. Assessments were made preoperatively and at follow-up, including physical examination (POP-Q) and standardised questionnaires (IIQ, UDI and DDI).
Results
Five hundred and five patients were included with a median follow-up of 12.7 (6–35) months. Bothersome OAB symptoms decreased after POP surgery. De novo bothersome OAB symptoms appeared in 5–6% of the women. Frequency and urgency were more likely to improve as compared with urge incontinence and nocturia. The best predictor for the absence of postoperative symptoms was the absence of preoperative bothersome OAB symptoms.
Conclusion
The absence of bothersome OAB symptoms preoperatively was the best predictor for the absence of postoperative symptoms.
doi:10.1007/s00192-010-1152-y
PMCID: PMC2910298  PMID: 20419366
Overactive bladder; Urgency; Urge incontinence; Frequency; Nocturia; Pelvic organ prolapse
18.  How to write an ICS/IUGA conference abstract 
Introduction
This article aims to condense the lectures and discussions from workshops on good reporting at IUGA Como 2009 and ICS San Francisco 2009, providing practical advice for the novice researcher summarising their data for the first time.
Conclusions
Drafting an abstract can be a time consuming process. Formal guidance, such as CONSORT and STROBE, exists for the kinds of information that should be included regarding almost all designs of clinical trials. Follow the abstract submission rules closely to avoid outright rejection. Plan to highlight the novelty, scientific merit and clinical impact of the work. Try not to overstate the importance of the findings. Do not forget to publish the work in a peer reviewed journal.
doi:10.1007/s00192-010-1117-1
PMCID: PMC2845882  PMID: 20179902
Abstracting and indexing; Clinical trials; Congresses; Medical societies; Peer review
19.  Midline fascial plication under continuous digital transrectal control: which factors determine anatomic outcome? 
Introduction and hypothesis
The aim of the study was to report anatomic and functional outcome of midline fascial plication under continuous digital transrectal control and to identify predictors of anatomic failure.
Methods
Prospective observational cohort. Anatomic success defined as POP-Q stage ≤ I of the posterior compartment. Validated questionnaires to measure bother and impact on quality of life. Logistic regression to identify risk factors for anatomic failure.
Results
Two hundred thirty-three patients with posterior pelvic organ prolapse (POP) stage ≥ II underwent midline fascial plication under continuous digital transrectal control. Median follow-up was 14 months (12–35 months), and anatomic success was 80.3% (95% CI 75–86). Independent predictors of failure were posterior compartment POP stage ≥ III [OR 8.7 (95% CI 2.7–28.1)] and prior colposuspension [OR 5.6 (95% CI 1.1–27.8)]. Sixty-three percent of patients bothered by obstructed defaecation experienced relief after surgery.
Conclusions
Anatomic and functional outcomes were good. Risk factors for anatomic failure were initial size of posterior POP (stage ≥ III) and prior colposuspension.
doi:10.1007/s00192-010-1097-1
PMCID: PMC2858280  PMID: 20146055
Anatomic; Colposuspension; Continuous digital transrectal control; Midline fascial plication; Posterior wall; Prolapse repair
20.  Perineal descent and patients’ symptoms of anorectal dysfunction, pelvic organ prolapse, and urinary incontinence 
Introduction and hypothesis
The aim of this dynamic magnetic resonance (MR) imaging study was to assess the relation between the position and mobility of the perineum and patients’ symptoms of pelvic floor dysfunction.
Methods
Patients’ symptoms were measured with the use of validated questionnaires. Univariate logistic regression analyses were used to study the relationship between the questionnaires domain scores and the perineal position on dynamic MR imaging, as well as baseline characteristics (age, body mass index, and parity).
Results
Sixty-nine women were included in the analysis. Only the domain score genital prolapse was associated with the perineal position on dynamic MR imaging. This association was strongest at rest.
Conclusions
Pelvic organ prolapse symptoms were associated with the degree of descent of the perineum on dynamic MR imaging. Perineal descent was not related to anorectal and/or urinary incontinence symptoms.
doi:10.1007/s00192-010-1099-z
PMCID: PMC2858277  PMID: 20135303
Dynamic MR imaging; Pelvic floor; Perineal descent; Prolapse; Urinary incontinence; Symptoms
21.  Does trocar-guided tension-free vaginal mesh (Prolift™) repair provoke prolapse of the unaffected compartments? 
Introduction and hypothesis
The objective of this study was to assess the effect of the tension-free vaginal mesh (Prolift™) procedure on the non-treated and initially unaffected vaginal compartments.
Methods
This prospective observational cohort study involved 150 patients who underwent a Prolift™ procedure. Pelvic organ prolapse (POP) quantification and evaluation of prolapse symptoms with validated questionnaires was performed pre-operatively and 6 and 12 months postoperatively. Primary outcome was the rate of POP stage ≥II in the non-treated vaginal compartments.
Results
Twenty-three percent of all patients developed a de novo POP stage ≥II in the untreated compartment. This occurred in 46% and 25% of patients after an isolated anterior and isolated posterior Prolift™, respectively.
Conclusion
Tension-free vaginal mesh treatment of one vaginal compartment seems to provoke the development of vaginal prolapse in initially unaffected vaginal compartments, particularly after an isolated anterior Prolift™ procedure.
doi:10.1007/s00192-009-1028-1
PMCID: PMC2815797  PMID: 19902132
Prolift™; Pelvic organ prolapse; Unaffected vaginal compartment; Mesh; Trocar-guided; Tension-free
22.  The effectiveness of surgical correction of uterine prolapse: cervical amputation with uterosacral ligament plication (modified Manchester) versus vaginal hysterectomy with high uterosacral ligament plication 
Introduction and hypothesis
The objective of this study is to evaluate cervical amputation with uterosacral ligament plication (modified Manchester) and compare it to vaginal hysterectomy with high uterosacral ligament plication procedure with special regard to the middle compartment.
Methods
Consecutive women with pelvic organ prolapse who underwent either vaginal hysterectomy or a modified Manchester procedure were included. Assessments were made preoperatively and at 1-year follow-up, including physical examination with pelvic organ prolapse quantification standardised questionnaires (incontinence impact questionnaire, urogenital distress inventory, and defaecatory distress inventory).
Results
Between 2002 and 2007, 156 patients were included. Ninety-eight patients returned for a 1-year follow-up. In the modified Manchester group, we found no middle compartment recurrence versus two (4%) in the vaginal hysterectomy group. Anterior and posterior compartment prolapse recurrences (stage ≥2) were similar (approximately 50%). Considering operating time and blood loss, modified Manchester was more favourable. There was no difference in the pre- and postoperative subjective scores. The overall functional outcome was acceptable.
Conclusions
We found an excellent performance of both procedures regarding middle compartment recurrences.
doi:10.1007/s00192-009-0945-3
PMCID: PMC2762528  PMID: 19669686
Cervical amputation; Hysterectomy; Manchester; Pelvic organ prolapse; POP-Q; Uterosacral ligament
23.  Symptoms of pelvic floor dysfunction are poorly correlated with findings on clinical examination and dynamic MR imaging of the pelvic floor 
Introduction and hypothesis
The aim of the study was to determine whether patients’ symptoms agree with findings on clinical examination and dynamic MR imaging of the pelvic floor.
Methods
Symptoms of pelvic organ dysfunction were measured with the use of three validated questionnaires. The domain scores were compared with POP-Q and dynamic MR imaging measurements. The Spearman’s rank correlation coefficient (rs) was used to assess agreement.
Results
Only the domain score genital prolapse was significantly correlated in the positive direction with the degree of pelvic organ prolapse as assessed by POP-Q and dynamic MR imaging (rs = 0.64 and 0.27, respectively), whereas the domain score urinary incontinence was inversely correlated (rs = −0.32 and −0.35, respectively).
Conclusions
The sensation or visualization of a bulge in the vagina was the only symptom which correlated positively with the degree of pelvic organ prolapse, and clinical examination and dynamic MR imaging showed similar correlation in this respect.
doi:10.1007/s00192-009-0938-2
PMCID: PMC2744799  PMID: 19597719
Agreement; Magnetic resonance imaging; Pelvic organ prolapse; POP-Q; Questionnaire; Symptom
24.  Trocar-guided total tension-free vaginal mesh repair of post-hysterectomy vaginal vault prolapse 
Introduction and hypothesis
The objective of this study was to report 1 year anatomical and functional outcomes of trocar-guided total tension-free vaginal mesh (Prolift™) repair for post-hysterectomy vaginal vault prolapse with one continuous piece of polypropylene mesh.
Methods
We conducted a prospective observational cohort study of 46 patients. A minimum sample size of 35 patients was needed to detect a recurrence rate of less than 20% at 12 months. Instruments of measurement used were pelvic organ prolapse quantification and validated questionnaires.
Results
Overall anatomical success was 91% (95% confidence interval 83–99), with significant improvement in experienced bother and quality of life. Mesh exposure occurred in seven patients (15%). No adverse effects on sexual function could be detected.
Conclusions
Trocar-guided total tension-free vaginal mesh (Prolift™) repair with one continuous piece of mesh for post-hysterectomy vaginal vault prolapse is well tolerated and anatomically and functionally highly effective. Results of controlled trials will determine its position in the operative armamentarium.
doi:10.1007/s00192-009-0924-8
PMCID: PMC2744794  PMID: 19499156
Exposure; Mesh; Tension-free; Total repair; Trocar-guided; Vault prolapse
25.  Pelvic floor muscle function in a general female population in relation with age and parity and the relation between voluntary and involuntary contractions of the pelvic floor musculature 
Introduction and hypothesis
The objective of this study is to describe pelvic floor muscle function (PFMF) in relation to age and parity in a general female population and to test whether strength/endurance measurements represent all functions of the pelvic floor musculature.
Methods
A cross-sectional study was performed on 95% of the women aged 45–85 years from a small Dutch town. Validated questionnaires were used to obtain general information, and vaginal examination to test PFMF was performed on 649 women. Chi-square tests were used to analyse the relation between PFMF versus age and parity. Analysis of variance was used to compare muscle strength and endurance to the other PFMF items.
Results
Response rate to the questionnaire was 62.7% (1,869/2,979). PFM strength and endurance are not positively associated with the effective involuntary muscle contractions during coughing.
Conclusions
Voluntary muscle contractions decreased with age, but there was no relation with parity. Muscle strength and endurance measurements alone are not sensitive enough to determine PFMF.
doi:10.1007/s00192-009-0978-7
PMCID: PMC2834770  PMID: 19756345
Female; Function; Pelvic floor musculature; Prevalence; Involuntary muscle contraction

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